BeMorr Client Intake Form

BeMorr Society

CLIENT INTAKE FORM
If you are in Immediate Crisis contact your local distress centre

BC Crisis Centre at 1-800-784-2433

Talk Suicide Canada at 1-833-456-4566

Suicide Crisis Helpline 988

Call 911.

**Please note that BeMorr Society is Not a Crisis line or Crisis centre. We provide mental health support.**
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityProvince

Postal Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Emergency Contact

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.
Are you in need of Immediate support?*

YESNO
If you are in Immediate Crisis contact your local distress centre, or the BC Crisis Centre at 1-800-784-2433, Talk Suicide Canada at 1-833-456-4566, Suicide Helpline 988, or call 911
Please describe the urgency of your request.*
What are you seeking?
Which service are you interested in receiving?*
Is there a specific counsellor you would like to see? (Please see our Partnered Counsellor Bios) *we will try to accommodate your choice*
Insurance Coverage*

I have insurance coverageI do not have insurance coverageI don't know
My Annual Income level is*

less than $35,000 per yearless than $50,000 per yearover $50,000 per year
My Annual income is..
What is you monthly budget for counselling?
My budget is $(enter amount)* per month for counselling or other services.

BeMorr Society